A postsurgical client has been receiving morphine by patient-controlled analgesia for 2 days. What action by the nurse best addresses potential adverse effects?
administering a stool softener as prescribed
auscultating the client's lung for adventitious sounds
encouraging active range of motion exercises
applying calf compressors as prescribed
The Correct Answer is A
A. Administering a stool softener is essential as opioids like morphine commonly cause constipation, and this proactive measure helps mitigate that adverse effect.
B. While auscultating the lungs is important to monitor respiratory function, it does not specifically address a common adverse effect of morphine.
C. Encouraging active range of motion exercises can help prevent complications from immobility but does not directly address the most common adverse effect of morphine.
D. Applying calf compressors can help prevent deep vein thrombosis, but it is not the most effective action for addressing the specific adverse effects of morphine use.
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Correct Answer is A
Explanation
A. Blood pressure is correct because both nitroglycerin and diltiazem can cause vasodilation, leading to hypotension; thus, monitoring blood pressure is crucial for patient safety.
B. Level of consciousness is incorrect; while important, it is not the primary concern in this context.
C. Daily weights are incorrect; they are more relevant for assessing fluid status over time, not immediate drug effects.
D. Respiratory status is incorrect; while monitoring is important, blood pressure takes precedence due to the risk of hypotension associated with these medications.
Correct Answer is A
Explanation
A. A return to normal respiratory rate, rhythm, and depth is correct because opioid antagonists, such as naloxone, are primarily used to reverse the respiratory depression caused by opioid overdose.
B. Management of alcohol withdrawal symptoms is incorrect; opioid antagonists do not address alcohol withdrawal.
C. A reduction in the client's rating of their pain is incorrect; opioid antagonists counteract the effects of opioids, which can result in increased pain levels rather than reduction.
D. Alertness and improve memory function is incorrect; while opioid antagonists may improve alertness by reversing sedation, the primary goal focuses on restoring respiratory function.